PTO TRAINING APRIL 3RD, 11:00 AM Call Instructions: Please Mute - PowerPoint PPT Presentation

PTO TRAINING APRIL 3RD, 11:00 AM Call Instructions: Please • Mute your phone, microphone, and speakers on your computer/device • Turn off the zoom video feature • Enter your name/organization in the chat box feature for attendance • Submit questions via the chat box feature • Questions will be answered following the presentation • Time to ask questions via audio will be offered for those on the phone 1

CQM WEBINAR TUESDAY, APRIL 3 11:00 AM – 12:00 PM

AGENDA TCPI and ENSW updates Conflict of Interest Forms Q4 CQM data report 3 Q1 CQM reporting requirements Extended CHITA services for COHORT 1 Q&A

TCPI UPDATE TCPi: Please submit all Clinical Quality Measures by 04/26/18 All CQMs will be submitted through the Healthcare Communities tool TCPi CHITA Field Note – Due for first Quarter. NQF PQRS Description Weight assessment and counseling for nutrition and NQF 0024 physical activity for children and adolescents. PQRS 239 Body Mass Index (BMI) NQF 0421 screening and follow-up. PQRS 128 Tobacco use assessment and tobacco cessation NQF 0028 intervention. PQRS 226 Blood pressure control. PQRS 236 NQF 0018 HbA1c control for patients NQF 0059 with diabetes. PQRS 001 Screening for clinical NQF 0418 depression and follow-up plan. PQRS 134 Developmental screening in NQF 1448 the first 3 years of life. PQRS n/a 4

TCPI NATIONAL QUALITY MEASURE COLLECTION TOOL We will be using the TCPi National CQM collection tool this Quarter Please login through SPLIT to access the CQM survey SPLIT training will be held on 4.10.18 during the TCPi PTO call All CHITAs are being asked to submit CQMs on behalf of their practices All CHITAs should have created their own login to the Healthcare Community website and requested access to the TCPi Community. Once Logged in please select the TCPi community and Outcomes Sharing on the left side of the screen to access the CQM reporting page. 5

ENSW UPDATE ▪ Please ensure all measures are reported by April 30 th , 2018 ▪ 12 month and 15 month CQMs. Please work with practices to collect and submit 12 month and 15 month CQMs 6

SIM Q4 CQM DATA

Percentage of active primary care practice sites reporting CQMs each quarter 98.9% 100.00% 99.35% 98.0% 100.0% 98.9% 95.0% 97.40% 90.2% 97.0% 90.0% 87.0% 85.0% 80.65% 80.0% 79.3% 80.0% 75.0% Cohort 1 - 1 or more CQMs 70.0% Cohort 1 - Required number of CQMs 65.0% 64.0% 64.0% 60.0% Cohort 2 - 1 more more CQMs 55.0% Cohort 2 - Required number of CQMs 50.0% 2016 Q1 2016 Q2 2016 Q3 2016 Q4 2017 Q1 2017 Q2 2017 Q3 2017 Q4 (optional for (optional for cohort 1) cohort 2)

SIM Q4 CQM DATA REPORT ▪ Q4 Cohort 1 CQM Reporting Breakdown ▪ Adult (6) 51 of 53 Req ▪ Pediatric (4) 19 of 22 Req ▪ Adult CPC+ (5) 17 of 17 Req ▪ Total Practices 92 9

SIM Q4 CQM DATA REPORT ▪ Q4 Cohort 2 CQM Reporting Breakdown ▪ Adult (6) 95 of 97 Req ▪ Pediatric (4) 35 of 37 Req ▪ Adult CPC+ (5) 20 of 20 Req ▪ Total Practices 154 10

Number SIM primary care practice sites (N=246) that reported on each CQM in Q4 of 2017 Depression Screening and Follow-up 200 SUD: Tobacco Use 177 Hypertension 172 Diabetes: A1c 168 Adult Obesity Screen 151 Fall Safety 110 Asthma Medication Management 105 Adolescent Obesity Screen (Diet) 82 Adolescent Obesity Screen (Activity) 82 Adolescent Obesity Screen 82 SUD: Alcohol and Other Drug Dependence 38 Maternal Depression Screening 36 Depression Remission at 12 months* 35 Developmental Screening 29 SUD: Alcohol 9 0 50 100 150 200 250 *This measure is only available for practices that are in both SIM and CPC+

Aggregate values of CQMs reported on by SIM primary care practice sites in Q4 of 2017 100.00% 99.90% 85.64% 90.00% 81.20% 79.41% 80.00% 68.26% 66.61% 70.00% 62.49% 63.73% 55.69% 60.00% 55.56% 53.01% 50.00% 40.00% 28.16% 30.00% 18.82% 20.00% 14.26% 9.63% 10.00% 0.00%

Aggregate percent of eligible patients screened for depression over time as reported by the CMHCs and cohorts 1 & 2 70.00% 58.30% 61.20% 60.00% 56.32% 49.71% 50.00% 55.00% 49.20% 40.00% 30.00% 34.30% 20.00% 10.00% 0.00% 2016 Q2 2016 Q3 2016 Q4 2017 Q1 2017 Q2 2017 Q3 2017 Q4 Cohort 1 Cohort 2 CMHCs 13

MOST COHORT 1 PRACTICES HAVE IMPROVED THEIR DEPRESSION SCREENING AND FOLLOW-UP 57 practices improved on their reported percent of eligible patients screened for depression 22 practices didn’t report on this measure at all or only reported on it in either Q4 of 2016 or Q4 of 2017 13* practices reported lower values in Q4 of 2017 compared to 2016 * 2 of these practices reported 1% or less difference between the two reporting periods and both were above the 2017 reported cohort average (55%) 14

Q1 2018 SIM CQM REPORTING REQUIREMENTS

Q1 REPORTING REQUIREMENTS AND SCHEDULE SIM Q1 2018 CQM reporting requirements ▪ Practice sites choose: trailing 12 months (preferred) or year-to-date ▪ Q1 report due April 30th, 2018 16

REPORTING SCHEDULE: ADULTS COHORT 1 2016 Q1 (Jan-Mar 16) 2016 Q2 (Apr-Jun 16) 2016 Q3 (Jul-Sep 16) 2016 Q4 (Oct-Dec 16) Test period, practice sites report whatever Choose 3 core CQMs: Choose 3 core CQMs (same as Q2) Report 4 core CQMs (non-Mathematica):   they can Asthma Asthma   Influenza Influenza   Depression OR Maternal Depression Depression OR Maternal Depression   Obesity: Adult Obesity: Adult and 1 non-core CQM (non-Mathematica):  Diabetes: Hemoglobin A1c  Fall Safety  Hypertension = 5 total CQMs 2017 Q1 (Jan-Mar 17) 2017 Q2 (Apr-Jun 17) 2017 Q3 (Jul-Sep 17) 2017 Q4 (Oct-Dec 17) Choose 5 primary CQMs: Report all 6 primary CQMs: Same as Y2Q2 Same as Y2Q2     Depression Screening Depression Screening Phase in additional secondary CQMs Phase in additional secondary CQMs   Diabetes: Hemoglobin A1c Diabetes: Hemoglobin A1c as appropriate as appropriate   Hypertension Hypertension = 6 total CQMs required = 6 total CQMs required   Obesity: Adult Obesity: Adult   SUD: Alcohol & Other Drug SUD: Alcohol & Other Drug Dependence Dependence   SUD: Tobacco SUD: Tobacco Secondary CQMs (if needed): Secondary CQMs (if needed):   Asthma (new) Asthma (new)   Fall Safety Fall Safety   Maternal Depression Screening Maternal Depression Screening   SUD: Alcohol SUD: Alcohol = 5 total CQMs required = 6 total CQMs required Cohort 1 SIM CQM Reporting Schedules: http://www.practiceinnovationco.org/wp-content/uploads/2017/02/SIM-Clinical-Quality-Measures-CQM-Reporting-Schedules-Cohort-1.pdf 17

REPORTING SCHEDULE: PEDS COHORT 1 2016 Q1 (Jan-Mar 16) 2016 Q2 (Apr-Jun 16) 2016 Q3 (Jul-Sep 16) 2016 Q4 (Oct-Dec 16) Test period, practice sites report whatever choose 3 core CQMs: choose 3 core CQMs (same as Q2) Report 5 core CQMs (non-Mathematica):   they can Asthma Asthma   Depression Depression   Influenza Influenza   Maternal Depression Maternal Depression   Obesity: Adolescent Obesity: Adolescent 2017 Q1 (Jan-Mar 17) 2017 Q2 (Apr-Jun 17) 2017 Q3 (Jul-Sep 17) 2017 Q4 (Oct-Dec 17) Report all 4 primary CQMs: Same as Y2Q1 Same as Y2Q1 Same as Y2Q1     Depression Screening Phase in additional secondary CQMs Phase in additional secondary CQMs Phase in additional secondary CQMs  Developmental Screening as appropriate as appropriate as appropriate  Maternal Depression Screening = 4 total CQMs required = 4 total CQMs required = 4 total CQMs required  Obesity: Adolescent Secondary CQMs (if needed):  Asthma (new) = 4 total CQMs required Cohort 1 SIM CQM Reporting Schedules: http://www.practiceinnovationco.org/wp-content/uploads/2017/02/SIM-Clinical-Quality-Measures-CQM-Reporting-Schedules-Cohort-1.pdf 18

REPORTING SCHEDULE: CPC+ COHORT 1 2016 Q1 (Jan-Mar 16) 2016 Q2 (Apr-Jun 16) 2016 Q3 (Jul-Sep 16) 2016 Q4 (Oct-Dec 16) Same as Cohort 1 SIM Only (see above) Same as Cohort 1 SIM Only (see above) Same as Cohort 1 SIM Only (see above) Same as Cohort 1 SIM Only (see above) 2017 Q1 (Jan-Mar 17) 2017 Q2 (Apr-Jun 17) 2017 Q3 (Jul-Sep 17) 2017 Q4 (Oct-Dec 17) Choose 4 primary CQMs: Report all 5 primary CQMs: Same as Y2Q2 Same as Y2Q2     Depression: Depression: Phase in additional secondary CQMs Phase in additional secondary CQMs a) Depression Screening (SIM/QPP) OR a) Depression Screening OR as appropriate as appropriate b) Depression Remission at 12 months b) Depression Remission at 12 months = 5 total CQMs required = 5 total CQMs required  (CPC+ group 1) Diabetes: Hemoglobin A1c   Diabetes: Hemoglobin A1c (CPC+ Hypertension  group 1 & SIM/QPP) SUD: Alcohol & Other Drug  Hypertension (CPC+ group 1 & Dependence  SIM/QPP) SUD: Tobacco  SUD: Alcohol & Other Drug Secondary CQMs (if needed):  Dependence (CPC+ group 2 & Asthma  SIM/QPP) Fall Safety   SUD: Tobacco (CPC+ group 3 & Maternal Depression Screening  SIM/QPP) SUD: Alcohol Secondary CQMs (if needed): = 5 total CQMs required  Asthma (SIM/QPP)  Fall Safety (CPC+ group 2 & SIM/QPP)  Maternal Depression Screening (SIM/QPP)  SUD: Alcohol (SIM/QPP) = 4 total CQMs required Cohort 1 SIM CQM Reporting Schedules: http://www.practiceinnovationco.org/wp-content/uploads/2017/02/SIM-Clinical-Quality-Measures-CQM-Reporting-Schedules-Cohort-1.pdf 19